AGENCY: Department of Health and Human Services. Healthcare Administration. Division of Integrated Healthcare. Office of Medicaid Operations.
SERIES: 7888
TITLE: Health insurance claim form
DATES: 1985-
ARRANGEMENT: None
DESCRIPTION: This is a claim submitted by medical providers for services rendered under medicare and medicaid programs. The form includes patient's name, address, telephone number, date of birth, and sex, name and address of the insured party, the insured's identification number and group number, the relationship between the patient and the insured, the name, address, policy number, and policy holder of other health insurance coverage, if any; whether the patient's condition was related to his/her employment or an accident; the signatures and dates of signature of the patient and the person who is to authorize payment; the date of the illness or injury, the date the patient first consulted the physician, the date the patient can return to work, and if the patient is disabled, the dates of partial or total disability; whether the patient has previously had these symptoms, the name of the referring physician, the provider license number, the dates the patient admitted to and discharged from a hospital, the name and address of the medical facility where the services were rendered, whether laboratory work was performed and the amount of charges, the diagnosis, the dates of medical service, the place of service, the procedure code, a description of the services and supplies furnished for each date, the amount of the charges, the name, address, and identification number of the physician or supplier, the provider type, the social security number, employer identification number, and signature of the physician or supplier, the patient's account number, the total charge, the amount paid by the patient, the balance due, and the date the form was completed.
RETENTION
Retain for 1 year(s)
DISPOSITION
Destroy.
RETENTION AND DISPOSITION AUTHORIZATION
These records are in Archives' permanent custody.
FORMAT MANAGEMENT
Paper: Retain in Office for 1 month and then transfer to State Records Center. Retain in State Records Center for 11 months and then microfilm and destroy provided microfilm has passed inspection.
APPRAISAL
Administrative Fiscal
Previous decision: RDR 79-142: 1 year and microfilm/confidential.
PRIMARY DESIGNATION
Private